Case Notes and Treatment Planning

Case Notes

Arrrrrgggghhhhh. Everyone’s favourite part of being a therapist (not). The thing about writing case notes that is most frustrating is that everyone tells you that you need to write them, but no one tells you how to write them. There is such a lack of guidance around this topic that leaves you feeling insecure and always feeling ‘not quite good enough.’ The guidelines that have been provided are vague and open to interpretation, you can find the ACA and PACFA guidelines to case notes in the attachment section of this lesson.  

There is a whole other course specifically designed to take you through how to write case notes and treatment plans, but for now, here is some general guidance about what to put and not to put in your case notes. 

What needs to be in session notes

These guidelines are taken from the PACFA recommendations:

Session notes should include impartial, respectful and accurate chronological summaries of interactions, observations and interventions used during client sessions.

When deciding on what information to include in a session note, the guiding principle is whether it is relevant to the specific service or intervention being provided.

Since the primary purpose of session notes is to support our work with the client, session notes typically contain:

• Date and time of attendance and session number

• A summary of what the client shared and what was objectively observed by the practitioner

• A record of interventions used by the practitioner

• A record of any strategies pursued, and any actions taken, with an explanatory note for such actions

• Any correspondence and contact since the previous session

• Any homework set

• Details if a referral has been made

• Plan for future sessions.

In writing our session notes the question to ask is; “if I were to be called upon by a court to divulge my notes, would they be adequate and defensible?” If in doubt, supervision provides a safe space for discussion.

Guidance around case notes and reports: 

• Be objective – use words that precisely describe behaviours and not subjective interpretation. Saying “the client was not interested in the session” is an opinion; you cannot assume you know the intent of the client. You can write in the observation section, “Client was yawning and looking at their watch multiple times in the session” or “Client repeatedly asked if the session was over” to describe the specific behaviours.
• Be professional – Write with professional authority. Be concise, consistent and specific. If you are too vague, it can be mistaken as incompetence. Back yourself with your clinical opinion and treatment plan.
• Keep it short. Clinical notes should be brief and factual, containing concise details of what was discussed in the session and not the personal opinions of the therapist. Write as little as possible but as much as to get the main just of the session.
• Use a template. Using a template such as the BPSS for your initial notes and the PIRP, SOAP or DAP for ongoing notes can help you keep your notes on track and help focus the sessions and treatment plans.
• Audit your notes regularly. If you find yourself taking longer than 10 minutes to write case notes, you may be overcomplicating the process. Audit how long it takes you to write them and also their quality and content. You can have a supervisor look over your notes and get feedback on how you are doing.